AS THE MOTHER of three children age 6 and under, Carrie Herzke, MD, claims that going grocery shopping with all three in tow has given her key insights into how to negotiate expectations with even the most difficult patients.

“You have to say ‘no’ and mean it,” said Dr. Herzke, during a presentation on patient expectations at this spring’s Society of Hospital Medicine meeting. “You have to give difficult patients options, carefully choose your battles and not get frantic.”

According to Dr. Herzke, clinical director of hospital medicine and assistant professor of medicine and pediatrics at Baltimore’s Johns Hopkins University, doctors have to negotiate expectations for patients who feel entitled to narcotics for chronic pain, demand excessive amounts of time or insist that physicians provide them a cure despite their widely metastatic cancer. Research suggests that patients who are labeled as “difficult” tend to ignore medical recommendations and are perceived as mean, belligerent or needy—or all three.

“Find some ways to say ‘yes,’ and pick your battles carefully.”

~ Carrie Herzke, MD, Johns Hopkins University, Baltimore, MD

To diagnose and treat such patients, Dr. Herzke described communication techniques that couch the discussion as being all about them. But such techniques also help minimize the damage done to doctors and staff from what can be devastating interactions. Ultimately, she said, her goal is to teach providers how to set limits to ensure that patients get the best quality care. That’s not always possible if the patient is in complete control.

Instead, health care needs to be a partnership among patients, families and clinicians to work well. “Our goal,” said Dr. Herzke, “should be to feel good about ourselves and our care.”

Types of difficult behavior According to Dr. Herzke, different factors can create difficult patient interactions. The easiest to deal with are situational issues.

“The room is too hot, or you have to deliver bad news and you’re not comfortable doing so, or your pager just won’t stop going off, or there is a language barrier,” she said.

Then there are physician factors that come into play. “We’ve all had days when we’ve come to work with baggage,” she pointed out. Doctors can be fatigued or stressed, angry or defensive, or exhibit arrogant behavior. Further, what can be a difficult patient for one physician may be manageable for another.

“The poorer your social skills or the more junior you are in your career,” explained Dr. Herzke, “the more likely you are to rate patients as difficult.”

But then there are the “It’s you, not me” patient factors. An author in the April 20, 1978, issue of the New England Journal of Medicine, described four types of difficult patients. While Dr. Herzke stressed that physicians shouldn’t label patients, she noted that understanding different categories can help providers appreciate why such patients may be perceived as difficult:

• Dependent clingers have inexhaustible needs for medical attention. “They may start out saying that you’re the best provider ever, but they end up needing so much attention that you wish Verizon could just block their number,” Dr. Herzke said. “We want to avoid these patients because they drain us, but avoiding them makes them worse. They want your attention, so they’ll act out.”

While the typical physician response to such patients is aversion, these patients benefit from you seeing them twice a day, she said. “Otherwise, they will demand increasing amounts of your time, more than you have to give.”

• Entitled demanders are just as needy, but they don’t lead with flattery. Instead, they rely on intimidation. “These are the patients who threaten to sue, and they make us fearful and angry,” she said. “These are patients who need limits set, and that’s really hard.”

The last time she dealt with a family member who fit this description, she resorted to saying, ” ‘Things aren’t going well here, you’re really frustrated, I’m clearly not meeting your needs. I’ll be happy to help you find someone who can.’ Once I established that I was not going to be nervous, we were able to actually form a relationship and move forward.”

• Manipulative help-rejectors tend to be ungrateful, but at least they’re not threatening. But nothing ever helps them, Dr. Herzke explained, and once you resolve one symptom, another quickly arises.

“Like clingers, these patients need to see us often.” But because such patients just go from one symptom to the next, they elicit a lot of physician anxiety. “We’re afraid we’re going to miss a diagnosis,” she said. For physicians, that can cause feelings of inadequacy and helplessness or depression.

• Finally, self-destructive deniers often exhibit suicidal behaviors that are manifested in being stubbornly non-adherent.

“These patients seem to be trying to destroy themselves,” she said. “They’re the ones who swear they’re going to cure their cancer or HIV with herbal remedies.” Such patients make doctors feel very conflicted and, given their self-destructive behavior, they can be very hard to watch. “Sometimes,” she said, “we see only pain in front of them, and we wish they’d die quickly.” Doctors need to recognize, she added, that such feelings “are really normal.”

Core rules In setting expectations, Dr. Herzke said the key is to maintain the discussion as being all about the patient, while setting necessary limits.

The narcotics epidemic, she pointed out, has given providers ample evidence that while it may be easy to give into patients, it can cause them harm. That’s why she believes it is important to frame “no” as being in the patients’ best interest.

“The more I can make it about them, the harder it will be for them to argue back,” she said. “When I keep repeating, ‘I want to help you,’ it’s harder for them to say, ‘Don’t help me.’ ”

At the same time, she holds fast to some core rules. First, there’s what she called the “Herzke rule”: If you can eat, you can take oral meds unless you have active cancer, sickle cell disease or another compelling reason why you need IV pain medication.

No. 2 is the PCA rule: All patients with chronic pain get a PCA, and she avoids IV boluses. Rule no. 3: Providers can’t say “no” and then give in.

And rule no. 5: Patients aren’t allowed to fire doctors. She will accommodate patient requests for another physician when those are based on religious beliefs or gender preferences.”

But if the patient gets frustrated and wants to fire a doctor, it doesn’t work that way,” she said. “The same is true with housestaff: Patients don’t get to fire them.” While there are some good reasons to allow patients to change physicians, permitting any patient to “fire” a provider makes it hard for clinicians to set appropriate limits.

Building relationships With difficult patients, Dr. Herzke relies on relationship-building techniques encapsulated in the PEARLS acronym:

Partnership: Let’s work together as a team

Empathy: That sounds miserable

Apology: I’m sorry that your illness …

Respects: I appreciate your willingness …

Legitimization: Anyone would be …

Support: We will help you through the next hours (days)

How do these rules and techniques play out in an actual encounter? When she comes to see a patient demanding narcotics for chronic pain, for instance, “I’ll let the patient vent, tell me how her pain is 10 out of 10, and then it’s my turn,” said Dr. Herzke. “I’ll start with, ‘I’m so sorry you’re in this situation, it must be terrible, clearly what we’re doing right now isn’t working for you. You’re on a lot of PCA—so we’re going to have to do something different.’ ”

That “something different” isn’t giving the patient the drug she has been demanding, if it is not medically appropriate. Instead, it may be stopping the PCA and switching to oral meds.

As patients argue back, Dr. Herzke pointed out that the blameless apology (“I’m so sorry you’re in this situation”) goes a long way. She also said she repeats the same pitch so often that “I become a broken record.”

The fine art of refusal At the same time, Dr. Herzke looks for ways to mitigate her changes by giving patients some options.

“I do better if I can offer choices, and patients feel the same way,” she pointed out. Before she walks into the patient’s room, she decides whether she’ll agree to narcotics or not and what alternatives she’ll present.

Her pitch goes like this: ” ‘I’m not going to give you Dilaudid because I won’t write a prescription for it when you go home and that seems so unfair to you,’ ” she said. ” ‘However, I can offer,’ and then I tell them whatever it is that I’ve decided on before-hand: tylenol, lidocaine patches, something medically appropriate.”

She also tries to give patients some control. “I’ll offer them one or two doses of IV pain medication that they can take whenever they want,” Dr. Herzke noted. “But I make it clear that it’s really just one or two doses, not one or two doses and then call me.”

She also doesn’t implement changes on difficult patients the first day she comes on service. “I’ll walk in, introduce myself and comment on their cool socks or their phone case, something that takes the focus off the elephant in the room,” she says. “Then the next day, I’ll start making changes to get patients on a more medically appropriate regimen.”

But starting that new regimen is useless unless you get every other provider on the same page. “If you say ‘no,’ but the night person gives patients what they want, you’re going to have a challenging day the next day,” she said. “The more you can convince patients that you’re all going to act the same, the more that encourages them to come along with you.” That approach, she noted, is also fair to patients because it is frustrating if the “rules” change every shift or day.

Winning the war To foster consistency, Dr. Herzke has also found it helpful to sometimes round with one of the patient’s subspecialists. “That way, we can’t be split,” she said.

“You get out of the ‘he said, you said’ situation. Patients deserve to have everyone be on the same page so they know what to expect.”

Another key: Engage in only those struggles that you can win and pick your fights carefully.

“If you’ve said ‘no PCA,’ you could probably stop the IV anti-emetics and Benadryl the same day”—but then your chances of having patients push back or fail to wean themselves from their PCA are much higher. “Stop the PCA, let them have their IV anti-emetics and re-evaluate those the next day,” said Dr. Herzke. “You’re trying to win the war, and that may mean losing some battles.” Ultimately, the goal is to partner with patients as much as possible.

As for patients who constantly demand time, Dr. Herzke recommended a different approach: telling them you have 15 minutes, so they should pick their three most important questions. If she doesn’t answer all three in 15 minutes, “I’ll say, ‘I have to come back’— and then I have to come back. You can’t set expectations and not live up to them.”

For patients who demand a cure, she again relies on the blameless apology, followed by options. “I’ll say, ‘I’m sorry you traveled all the way here,’ but then I’ll try to offer something. ‘We can’t offer a therapy or narcotics to solve your problem, but we do have symptom relief and great care.’ ”

They also make clear that patients agree to be treated. “It’s not appropriate for me to not check patients’ labs during an entire hospital stay,” she said. “We may agree that patients don’t need to have their labs checked at 2 a.m., and I’ll move that to 9:30 a.m. But patients can’t not have labs or not let me examine them.”

Patients may sign the contract or not, but even if they don’t sign, they need to understand that they must still abide by the rules. The trick is knowing what you can do to enforce the contract.

“If patients sign but break the rules and you don’t do anything, that sends the message that you won’t stand by what you have said,” Dr. Herzke explained. In such situations, she relies on her legal team. “I talk to the legal team before I go in so I know what I can do and say.” If you can’t enforce a contract, she added, don’t present patients with one.

When giving a contract to patients and explaining its implications, “I bring a patient advocate with me,” said Dr. Herzke. “That, again, makes it more about the patient.”

Contracts, of course, can also apply to family members, and Dr. Herzke has banned visitors who prove to be especially disruptive. While you always aim to partner with families, she said, “there are times when family members struggle to be appropriate advocates, and they can actually start to harm the therapeutic relationship.”

How does this play out in terms of patient satisfaction? “Such patients won’t be any more satisfied if you stop their PCA on day 14 than on day 2,” Dr. Herzke pointed out. “Patient experience is very important, but I don’t think we should provide poor or inappropriate medical care just to try to make patients happy.”

Several Approaches WHEN IT COMES to dealing with difficult patients, Carrie Herzke, MD, clinical director of hospital medicine and assistant professor of medicine and pediatrics at Baltimore’s Johns Hopkins University, recommends using an acronym that encapsulates several approaches. During a presentation at this spring Society of Hospital Medicine conference, Dr. Herzke explained that most of the steps are designed to help providers’ feel better (and recover faster from) difficult patient interactions.

Here’s the CALMER acronym:

C: catalyst for change

A: alter thoughts and change feelings

L: listen to make a diagnosis

M: make an agreement

E: education and follow-up

R: reach out and discuss feelings

As for change, the trick is to figure out what you can change and what you can’t. “If these patients are adults, we won’t be able to change their patterns of behavior over the course of a hospitalization,” said Dr. Herzke. “What we can change are our own reactions.”In terms of altering feelings, Dr. Herzke made it clear she was referring to providers’ feelings, not patients’. Once you identify your own feelings and work to get them under control, “hopefully, you can listen to the patient because he or she has medical problems.”

You then need to agree on and articulate a care plan (“we have agreed that … “). The next step is to discuss with the patient how to move forward and follow up.

And after a tough session of setting expectations, Dr. Herzke said she always tries to spend some moments in the hall with a nurse or a subspecialist who is also treating the patient. “It’s important to say, ‘That was really hard.’ That allows me to be respectful to the patient, but still acknowledge that the interaction was really draining.”

Taking that time also stops her from dragging all those emotions into her next patient encounter. “It also allows nurses to hear that I’m trying to help them because they get the brunt of all this.”

Dr. Herzke also reminded providers to step back and try to understand why patients are perceived as difficult. “This can help us to make sure we respect patients and their families,” she said, “even as we might work to set boundaries.”

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